London Journal of Primary Care 2011;4:69–71
# 2011 Royal College of General Practitioners
Ethics
Ethics of the ordinary: a meeting run by the Royal Society of Medicine with the Royal College of General Practitioners Andrew Papanikitas PhD Student, Department of Education and Professional Studies and Sessional Tutor, Department of Public Health and Primary Care, King’s College London, UK
Paquita De Zulueta Honorary Lecturer in Medical Ethics, Imperial College London and Tutor in Medical Ethics, Kings College London, UK
John Spicer Head of General Practice School, London Deanery, UK
Rhona Knight RCGP Ethics Committee and Portfolio GP, UK
Peter Toon Honorary Lecturer, Queen Mary University of London, UK
David Misselbrook Dean, Royal Society of Medicine, UK
Ethics has long been recognised as an integral element of primary healthcare.1 Despite the ubiquity of ethical challenges and dilemmas in primary care, it remains a neglected domain in the world of bioethics. Accordingly, there have been calls to explore the ethical dimensions of primary healthcare.2,3 On 15 February 2011 the Royal Society of Medicine ran a conference in association with the Royal College of General Practitioners in order to fulfil this need. The conference aspired to create a lively discourse between interested practitioners such that they had the opportunity to share ideas, research and literature in the context of primary healthcare ethics. This aspiration was fully met and 70 people convened, including medical students, academics and seasoned practitioners who made use of the opportunity to share their thoughts and experiences, research ideas and projects. The focus was on ‘everyday ethics’ – the moral dimensions underpinning interactions and relationships between clinicians, patients and their families and the subtle but complex ethical dimensions of everyday life. The recent changes to GP training and requirements for revalidation, and changes in societal attitudes provide an urgent need for a solid foundation of
a body of knowledge (both theoretical and empirical) and a community of scholars who are concerned with the ethics underpinning a vast majority of healthcare interactions. Two keynote speakers opened the event. Iona Heath, RCGP president, and Deborah Bowman, senior lecturer in medical ethics and law. Iona Heath’s inspirational talk highlighted the experience of the particular and how the uniqueness of individuals, their encounters and their narratives cannot be forced into a procrustean framework of rules and generalities. She outlined her view of the challenges facing ethical practice in primary care and emphasised the key role of compassion. Deborah Bowman, drawing from her own qualitative research, highlighted the extraordinary in the ordinary and how bioethics has not captured the ethics of the ordinary. She emphasised the centrality of relationships and the roles of the GP as advocate, holistic practitioner and healer. We explored three themes in the workshops: research in primary care ethics, issues affecting training and issues in practice. There were also 15 poster presentations. These could be categorised into two broad themes: the clinician–patient (or teacher–student) relationship and ‘micro-ethics’,4 exploring personal
70
A Papanikitas et al
and professional boundaries, the role of power, families, values and emotions in the relationship. The second theme was the exploration of the greater relevance and appropriateness of ethical paradigms other than the four principles, such as virtue ethics and feminist ethics for understanding and illuminating ethical problems, including rationing in healthcare.
Workshops
communicate or even be aware of one another. Similarly, relevant work is published in an array of journals that may not be linked to ethics or primary healthcare. There is also a ‘disconnect’ with the ordinary practitioner, who may not read bioethics journals or finds their technical language off-putting. There is a patchiness in knowledge of past and current research in primary care ethics, even by those who claim some expertise. The role or utility of this research was also discussed – would this inform courts, policy, and advice given by medical indemnifiers? Would this inform commissioning decisions?
Issues in training
Constraints
Tolerance of uncertainty and ambiguity
.
Training for uncertainty was a key issue and how experiential learning was needed to achieve this. Discussion revolved around how uncertainty of diagnosis and outcome links with evaluations of probability and risk and how to find the balance between complacency and crippling doubt. Self-awareness and reflexivity, accepting ambiguity, and patient prioritisation were discussed, as well as the responsibilities for teaching.
Issues for newly qualified GPs
.
Constraints to ethical patient-centred practice The workshop discussed how externally generated routine tasks and priorities such as targets and the quality and outcomes framework, and time constraints become part of everyday practice, creating distortions and infringements on the clinician–patient relationship and further reducing opportunities to identify the patient’s unstated issues.
.
Complexity Individuals are not social islands (or atomised entities) and often have multiple problems and difficulties demanding nuanced and multifaceted responses. .
Unrealistic expectations The workshop considered the credibility gap of unrealistic demands set against diminishing resources. How practitioners have to differentiate between needs and wants, rights and desires.
Issues in research Distinctiveness Many described the current shape of primary care ethics research as ‘indistinct’. Research is conducted in many centres by a variety of disciplines which may not
.
Researchers face a lack of interest by funding bodies and by professional colleagues. The time pressures for meeting the clinical and administrative loads constrains reflection and the ability to theorise, investigate and communicate results. Both ethics (empirical and theoretical) research and GP research are perceived by participants to have relatively low status. Opportunities made available to funded researchers, and grants are often part of a bloc piece of work. Funding is seen to be outcome or product driven which can create difficulties when there is uncertainty as to the measurable outcomes. The Research Ethics Committee approval process is a huge administrative burden. This inhibits clinicians and medical students from performing brief empirical studies, as the time taken for the protocol to be written and approved occupies the window of time available for the study (e.g. the final three months of an intercalated BSc). The dominance of the evidence-based medicine movement and the hegemony of RCTs creates difficulties for researchers exploring the ‘soft’ areas of medicine and undertaking qualitative research when they try to get their work published in the mainstream literature and high impact journals. Other barriers included risk to participants, and issues around informed consent from patients One group also felt that there was a crisis of reflexivity. Research involving ideas of right and wrong, good and bad, or attitudes and values, calls into question the bias or motivation of the researcher. There was a concern that a reflexive researcher might undermine their results by being perceived to have questionable motives! There was some discussion as to how theory and research might relate to the e-portfolio. There were concerns regarding the summative rather than formative aspect of the tool, of quantity more than quality.
Ethics of the ordinary
The future A community of primary care ethics researchers in the UK needs opportunities to meet face-to-face, to share ideas, present work and discuss the relevant literature. They need a database of researchers and literature, and a need to signpost work connected to particular methods and topics. Collaboration needs to be encouraged as successful projects involve a skill mix and possibly more than one academic discipline. Funding available to support primary care ethics research includes: .
.
.
.
The Wellcome Trust Biomedical Ethics and Humanities (clinician and non-clinician) – individual/strategic grants, the ESRC, the RCGP Scientific and the NIHR. Charities will also consider ethical/ sociological work linked to relevant issues. Researchers have been creative about applying for sociological or clinical charity grants, finding outcomes of interest to funding bodies. Researchers at various stages of their careers who are prepared to mentor those who are less experienced in navigating common barriers such as institutional support and REC approval would be of value. Engagement with several kinds of ‘public’ was identified as pivotal: – Both the general public and the primary care workforce for identification of relevant research themes. – With the press (medical and general) to facilitate public discourse. – With scholarly bodies and professional organisations to ensure understanding of professional standards as well as the attitudes and values of practitioners. – With policymakers and the public to promote understanding of the nature of primary health care, and better decision-making at both consultation and population levels.
These are interesting times. The RCGP has set up a centre for commissioning and now also a commission on the importance of generalism in practice. The conference organisers enjoined participants to collab-
71
orate with each other and provide a fertile ground for further work. For those who missed the ‘Ethics of the Ordinary’ Conference at the Royal Society of Medicine, our keynote speakers kindly agreed to be webcast - their presentations can be accessed by the links below. Iona Heath, President Royal College of General Practitioners, UK: www.rsmvideos.com/videoPlayer/?vid =152&class=videoThumbOdd Deborah Bowman, Senior Lecturer in medical law and ethics, St George’s medical School, UK: www.rsm videos.com/videoPlayer/?vid=153&class=videoThumb The conference also aimed to create a dedicated mailing list for similar events and a ‘virtual network’ for the sharing of events, research and education, please email [email protected] ACKNOWLEDGEMENTS
The event received generous funding from the Wellcome Trust, The Medical Protection Society and the Institute of Medical Ethics. REFERENCES 1 Papanikitas A and Toon P. Primary care ethics, a body of knowledge and a community of scholars? Journal of the Royal Society of Medicine 2010;104:94–6. 2 De Zulueta P. Primary care ethics. London Journal of Primary Care 2008;1:5–7. 3 Rogers WA. A systematic review of empirical research into ethics in general practice. British Journal of General Practice 1997;47:733–7. 4 Komesaroff P. Bioethics to microethics. In: Komesaroff P (ed) Troubled Bodies: critical perspectives on postmodernism, medical ethics and the body. Durham, NC: Duke University Press, 1995.
ADDRESS FOR CORRESPONDENCE
Email: [email protected] or andrew.papanikitas@ kcl.ac.uk Submitted 21 March 2011, accepted for publication 23 March 2011.
Read and comment on this article online at www.londonjournalofprimary care.org.uk/
# 2011 Royal College of General Practitioners
Ethics
Ethics of the ordinary: a meeting run by the Royal Society of Medicine with the Royal College of General Practitioners Andrew Papanikitas PhD Student, Department of Education and Professional Studies and Sessional Tutor, Department of Public Health and Primary Care, King’s College London, UK
Paquita De Zulueta Honorary Lecturer in Medical Ethics, Imperial College London and Tutor in Medical Ethics, Kings College London, UK
John Spicer Head of General Practice School, London Deanery, UK
Rhona Knight RCGP Ethics Committee and Portfolio GP, UK
Peter Toon Honorary Lecturer, Queen Mary University of London, UK
David Misselbrook Dean, Royal Society of Medicine, UK
Ethics has long been recognised as an integral element of primary healthcare.1 Despite the ubiquity of ethical challenges and dilemmas in primary care, it remains a neglected domain in the world of bioethics. Accordingly, there have been calls to explore the ethical dimensions of primary healthcare.2,3 On 15 February 2011 the Royal Society of Medicine ran a conference in association with the Royal College of General Practitioners in order to fulfil this need. The conference aspired to create a lively discourse between interested practitioners such that they had the opportunity to share ideas, research and literature in the context of primary healthcare ethics. This aspiration was fully met and 70 people convened, including medical students, academics and seasoned practitioners who made use of the opportunity to share their thoughts and experiences, research ideas and projects. The focus was on ‘everyday ethics’ – the moral dimensions underpinning interactions and relationships between clinicians, patients and their families and the subtle but complex ethical dimensions of everyday life. The recent changes to GP training and requirements for revalidation, and changes in societal attitudes provide an urgent need for a solid foundation of
a body of knowledge (both theoretical and empirical) and a community of scholars who are concerned with the ethics underpinning a vast majority of healthcare interactions. Two keynote speakers opened the event. Iona Heath, RCGP president, and Deborah Bowman, senior lecturer in medical ethics and law. Iona Heath’s inspirational talk highlighted the experience of the particular and how the uniqueness of individuals, their encounters and their narratives cannot be forced into a procrustean framework of rules and generalities. She outlined her view of the challenges facing ethical practice in primary care and emphasised the key role of compassion. Deborah Bowman, drawing from her own qualitative research, highlighted the extraordinary in the ordinary and how bioethics has not captured the ethics of the ordinary. She emphasised the centrality of relationships and the roles of the GP as advocate, holistic practitioner and healer. We explored three themes in the workshops: research in primary care ethics, issues affecting training and issues in practice. There were also 15 poster presentations. These could be categorised into two broad themes: the clinician–patient (or teacher–student) relationship and ‘micro-ethics’,4 exploring personal
70
A Papanikitas et al
and professional boundaries, the role of power, families, values and emotions in the relationship. The second theme was the exploration of the greater relevance and appropriateness of ethical paradigms other than the four principles, such as virtue ethics and feminist ethics for understanding and illuminating ethical problems, including rationing in healthcare.
Workshops
communicate or even be aware of one another. Similarly, relevant work is published in an array of journals that may not be linked to ethics or primary healthcare. There is also a ‘disconnect’ with the ordinary practitioner, who may not read bioethics journals or finds their technical language off-putting. There is a patchiness in knowledge of past and current research in primary care ethics, even by those who claim some expertise. The role or utility of this research was also discussed – would this inform courts, policy, and advice given by medical indemnifiers? Would this inform commissioning decisions?
Issues in training
Constraints
Tolerance of uncertainty and ambiguity
.
Training for uncertainty was a key issue and how experiential learning was needed to achieve this. Discussion revolved around how uncertainty of diagnosis and outcome links with evaluations of probability and risk and how to find the balance between complacency and crippling doubt. Self-awareness and reflexivity, accepting ambiguity, and patient prioritisation were discussed, as well as the responsibilities for teaching.
Issues for newly qualified GPs
.
Constraints to ethical patient-centred practice The workshop discussed how externally generated routine tasks and priorities such as targets and the quality and outcomes framework, and time constraints become part of everyday practice, creating distortions and infringements on the clinician–patient relationship and further reducing opportunities to identify the patient’s unstated issues.
.
Complexity Individuals are not social islands (or atomised entities) and often have multiple problems and difficulties demanding nuanced and multifaceted responses. .
Unrealistic expectations The workshop considered the credibility gap of unrealistic demands set against diminishing resources. How practitioners have to differentiate between needs and wants, rights and desires.
Issues in research Distinctiveness Many described the current shape of primary care ethics research as ‘indistinct’. Research is conducted in many centres by a variety of disciplines which may not
.
Researchers face a lack of interest by funding bodies and by professional colleagues. The time pressures for meeting the clinical and administrative loads constrains reflection and the ability to theorise, investigate and communicate results. Both ethics (empirical and theoretical) research and GP research are perceived by participants to have relatively low status. Opportunities made available to funded researchers, and grants are often part of a bloc piece of work. Funding is seen to be outcome or product driven which can create difficulties when there is uncertainty as to the measurable outcomes. The Research Ethics Committee approval process is a huge administrative burden. This inhibits clinicians and medical students from performing brief empirical studies, as the time taken for the protocol to be written and approved occupies the window of time available for the study (e.g. the final three months of an intercalated BSc). The dominance of the evidence-based medicine movement and the hegemony of RCTs creates difficulties for researchers exploring the ‘soft’ areas of medicine and undertaking qualitative research when they try to get their work published in the mainstream literature and high impact journals. Other barriers included risk to participants, and issues around informed consent from patients One group also felt that there was a crisis of reflexivity. Research involving ideas of right and wrong, good and bad, or attitudes and values, calls into question the bias or motivation of the researcher. There was a concern that a reflexive researcher might undermine their results by being perceived to have questionable motives! There was some discussion as to how theory and research might relate to the e-portfolio. There were concerns regarding the summative rather than formative aspect of the tool, of quantity more than quality.
Ethics of the ordinary
The future A community of primary care ethics researchers in the UK needs opportunities to meet face-to-face, to share ideas, present work and discuss the relevant literature. They need a database of researchers and literature, and a need to signpost work connected to particular methods and topics. Collaboration needs to be encouraged as successful projects involve a skill mix and possibly more than one academic discipline. Funding available to support primary care ethics research includes: .
.
.
.
The Wellcome Trust Biomedical Ethics and Humanities (clinician and non-clinician) – individual/strategic grants, the ESRC, the RCGP Scientific and the NIHR. Charities will also consider ethical/ sociological work linked to relevant issues. Researchers have been creative about applying for sociological or clinical charity grants, finding outcomes of interest to funding bodies. Researchers at various stages of their careers who are prepared to mentor those who are less experienced in navigating common barriers such as institutional support and REC approval would be of value. Engagement with several kinds of ‘public’ was identified as pivotal: – Both the general public and the primary care workforce for identification of relevant research themes. – With the press (medical and general) to facilitate public discourse. – With scholarly bodies and professional organisations to ensure understanding of professional standards as well as the attitudes and values of practitioners. – With policymakers and the public to promote understanding of the nature of primary health care, and better decision-making at both consultation and population levels.
These are interesting times. The RCGP has set up a centre for commissioning and now also a commission on the importance of generalism in practice. The conference organisers enjoined participants to collab-
71
orate with each other and provide a fertile ground for further work. For those who missed the ‘Ethics of the Ordinary’ Conference at the Royal Society of Medicine, our keynote speakers kindly agreed to be webcast - their presentations can be accessed by the links below. Iona Heath, President Royal College of General Practitioners, UK: www.rsmvideos.com/videoPlayer/?vid =152&class=videoThumbOdd Deborah Bowman, Senior Lecturer in medical law and ethics, St George’s medical School, UK: www.rsm videos.com/videoPlayer/?vid=153&class=videoThumb The conference also aimed to create a dedicated mailing list for similar events and a ‘virtual network’ for the sharing of events, research and education, please email [email protected] ACKNOWLEDGEMENTS
The event received generous funding from the Wellcome Trust, The Medical Protection Society and the Institute of Medical Ethics. REFERENCES 1 Papanikitas A and Toon P. Primary care ethics, a body of knowledge and a community of scholars? Journal of the Royal Society of Medicine 2010;104:94–6. 2 De Zulueta P. Primary care ethics. London Journal of Primary Care 2008;1:5–7. 3 Rogers WA. A systematic review of empirical research into ethics in general practice. British Journal of General Practice 1997;47:733–7. 4 Komesaroff P. Bioethics to microethics. In: Komesaroff P (ed) Troubled Bodies: critical perspectives on postmodernism, medical ethics and the body. Durham, NC: Duke University Press, 1995.
ADDRESS FOR CORRESPONDENCE
Email: [email protected] or andrew.papanikitas@ kcl.ac.uk Submitted 21 March 2011, accepted for publication 23 March 2011.
Read and comment on this article online at www.londonjournalofprimary care.org.uk/
